CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior Authorization Requirements for Rhode Island Medicaid

Lists prior authorization requirements and submission methods for participating UnitedHealthcare Community Plan of Rhode Island providers for inpatient and outpatient services; covers procedures, drugs, and services that require prior authorization.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateFeb. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal or call 855-766-0344.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Feb. 1, 2025effective date

online portalsubmission method

855-766-0344PA phone

multiple J-codesinjectable drugs flagged

SOS appliessite-of-service rule

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Services Requiring Prior Authorization — Coverage Criteria

The following services and items require prior authorization or notification as noted. This list consolidates requirements by service category and specific codes where provided. Providers should submit prior authorization requests through the payer’s portal or by the phone numbers indicated in the source material. Notification with service detail is required for certain inpatient post-acute facilities.

text":"Certain injectable colony-stimulating factor drugs and bone-modifying agents require prior authorization when administered outpatient; examples listed include eflapegrastim-xnst (J1449), filgrastim products (J1442, Q5110, Q5125, Q5101), pegfilgrastim products (J2506, Q5122, Q5120, Q5111, Q5108), sargramostim (J2820), tbo-filgrastim (J1447), trilaciclib (J1448), and denosumab for bone-modifying therapy (J0897)."}]},{"operator":"all","label":"Radiology and Advanced Imaging","children":[{"text":"Prior authorization required for advanced outpatient imaging requested by participating physicians — select CT, MRI, MRA, PET, nuclear medicine and nuclear cardiology procedures. Providers ordering these procedures must notify prior to scheduling; see Radiology Prior Authorization and Notification for CPT-level details."}]},{"operator":"all","label":"Surgery and Procedural Services","children":[{"text":"Prior authorization required for many outpatient surgical procedures including bariatric surgery (examples: 43644, 43645, 43659, 43770), cochlear and other auditory implants (e.g., 69710, 69714, 69930, L8614), functional endoscopic sinus surgery (FESS) codes (31240, 31253-31259, 31267, 31276, 31287, 31288), femoroacetabular impingement (29914-29916), gender dysphoria surgical treatments (authorization required with specified diagnosis codes F64.0-F64.8 and associated surgical codes such as 55970, 55980), and spinal, joint replacement and other major orthopedic procedures (see joint replacement code groups)."}]},{"operator":"all","label":"Transplants and Cellular Therapies","children":[{"text":"Prior authorization required for transplant services and CAR T-Cell therapies. For transplant and CAR T-Cell services, contact UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 or use the notification number provided."}]},{"operator":"all","label":"Durable Medical Equipment (DME), Orthotics and Prosthetics","children":[{"text":"Prior authorization required only for DME, orthotics and prosthetic codes listed with a retail purchase or cumulative rental cost greater than $500. Examples of DME/HCPCS that may require authorization: A9279, A9280, A9900, E0194, E0265, E0266 and select A- and L- codes listed for orthotics/prosthetics (L01xx, L04xx etc.)."}]},{"operator":"all","label":"Enteral and Home Nutrition Services","children":[{"text":"Prior authorization required for enteral services and certain in-home nutritional support and enteral therapy codes (examples: B4034, B4035, B4036, B4100, B4102-B4104, B4149, B4150, B4152-B4155, B4158-B4161, B9002, B9998)."}]},{"operator":"all","label":"Home Health and Private Duty Nursing","children":[{

text":"Prior authorization required for home health care when provided in outpatient settings (examples: G0299, G0300, G0493-G0496, S9122-S9123) and for private duty nursing (T1000)."}]},{"operator":"all","label":"Sleep and ENT Procedures","children":[{"text":"Prior authorization required for sleep studies (examples: 95805, 95807-95811, 95808, 95810) and for sleep apnea procedures/surgeries. Tonsillectomy/adenoidectomy and related ENT procedures may require prior authorization per the code groups listed."}]},{"operator":"all","label":"Vein, Vascular and Cardiac Procedures","children":[{"text":"Prior authorization required for lower extremity angiograms, selected vein procedures (e.g., 36473, 36475, 36478) and for certain outpatient diagnostic cardiac procedures (diagnostic catheterizations, echocardiograms, electrophysiology implants, stress echoes) when performed by participating physicians prior to performance."}]},{"operator":"all","label":"Site of Service Considerations","children":[{"text":"Prior authorization required when requesting services in an outpatient hospital setting; prior authorization is not required if services are performed at a participating Ambulatory Surgery Center (ASC) for certain codes (see SOS rules)."}]},{"operator":"all","label":"Potentially Unproven or Specialized Codes","children":[{"text":"Prior authorization required for potentially unproven services listed (example: 33289, C2624) and for select miscellaneous/unclassified codes where specific therapies require authorization (e.g., J3490, J3590, C9399 for certain cell and gene therapies)."}]},{"operator":"all","label":"Private Duty and Other Required Authorizations","children":[{"text":"Private duty nursing requires prior authorization (T1000). Zolgensma billed as J3399 requires prior authorization. Specific prior-notification instructions: some medications (Cimzia, Synagis) may require prior notification through OptumRx at 800-310-6826; many requests should be submitted via UnitedHealthcare Provider Portal or by calling the numbers in policy."}]},{"operator":"all","label":"Notification and Admission Requirements","children":[{"text":"Notification with service detail required for certain facility admissions (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long-term acute care hospitals, skilled nursing facilities). Prior authorization and notification of admission date are required for these post-acute inpatient services."}]}] }

Code Lists and Mappings (CPT / HCPCS / ICD-10)

Injectable colony-stimulating factors (require prior authorization)HCPCSCovered

J1449	Eflapegrastim-xnst (Rolvedon)
J1442	Filgrastim (Neupogen)
Q5110	Filgrastim-aafi (Nivestym)
Q5125	Filgrastim-ayow (Releuko)
Q5101	Filgrastim-sndz (Zarxio)
J2506	Pegfilgrastim (Neulasta)
Q5122	Pegfilgrastim-apgf (Nyvepria)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5108	Pegfilgrastim-jmdb (Fulphila)

1–10 of 13

1/2

Injectable erythropoiesis-stimulating agents (require prior authorization)HCPCSCovered

J0885

Erythropoiesis-stimulating agent (Procrit)

Bone-modifying agents (require prior authorization)HCPCSCovered

J0897

Denosumab (Xgeva)

Additional injectable medications (selected list)HCPCSCovered

Q5115	Truxima
Q5121	Avsola
Q5124	Byooviz
Q5128	Cimerli
Q5123	Riabni
Q5103	Inflectra
Q5130	Fylnetra
Q5119	Ruxience

White blood cell colony stimulating factors (reference list)HCPCS

J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim (Granix)
J1448	Trilaciclib (Cosela)
J2506	Pegfilgrastim (Neulasta)
Q5101	Filgrastim-sndz (Zarxio)
Q5108	Pegfilgrastim-jmdb (Fulphila)
Q5110	Filgrastim-aafi (Nivestym)
Q5111	Pegfilgrastim-cbqv (UDENYCA)
Q5120	Pegfilgrastim-bmez (Ziextenzo)
Q5122	Pegfilgrastim-apgf (Nyvepria)

1–10 of 11

1/2

Chemotherapy / Injectable outpatient (example)HCPCSCovered

J0801

Chemotherapy injectables (example)

Miscellaneous J/Q codes (selected)HCPCS

Q5110	Filgrastim-aafi (Nivestym) - listed also for reference
Q5125	Filgrastim-ayow (Releuko) - listed also for reference
Q5101	Filgrastim-sndz (Zarxio) - listed also for reference
Q5122	Pegfilgrastim-apgf (Nyvepria) - listed also for reference
Q5120	Pegfilgrastim-bmez (Ziextenzo) - listed also for reference

Continuous glucose monitor HCPCS (require prior authorization)HCPCSCovered

A4226	CGM supply
A4239	CGM transmitter
A9276	CGM sensor - example
A9277	CGM sensor - example

Orthotics and prosthetics (PA threshold)HCPCS

E0270	DME - wheelchair
E0277	DME - power wheelchair
L0112	Orthotic code example

ICD-10 diagnosis fragments (selected references)ICD-10

F64.0	Gender dysphoria
F64.1	Gender dysphoria
F64.2	Gender dysphoria
E10.52	Diabetes with peripheral angiopathy

Genetic / BRCA testing (prior authorization required outpatient)CPTCovered

81162	BRCA1/BRCA2 testing (example)
81163	BRCA testing (example)
81164	BRCA testing (example)

Radiation / advanced imaging guidance (selected)CPT

77014	IGRT
77385	IMRT planning
77520	Proton beam

Site-of-service outpatient hospital (selected procedural codes)CPTCovered

36590	Catheter-related procedure
30400	Rhinoplasty
45378	Colonoscopy

Selected reconstructive / physiologic function codes (partial)CPTCovered

67904	Eyelid procedure example
67911	Eyelid procedure example
67923	Reconstructive eyelid code
67924	Reconstructive eyelid code

Implantable device / bone growth stimulator (partial)HCPCSCovered

E0747	Bone growth stimulator - external
E0748	Bone growth stimulator - external
E0749	Bone growth stimulator - external
E0760	Bone growth stimulator - external

Potentially unproven services (examples)CPTExperimental

33289	Potentially unproven cardiac service
C2624	Potentially unproven HCPCS

Private duty nursing (prior authorization required)HCPCSCovered

T1000

Private duty nursing

How Providers Must Submit Prior Authorization and Key Action Items

Prior Authorization

How to obtain prior authorization

Submit prior authorization requests via the UnitedHealthcare Provider Portal (Prior Authorization and Notification tool) or by phone at 855-766-0344; prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Prior Authorization

Drug prior authorization requirement for injectable supportive and bone agents

Certain injectable colony-stimulating factors, erythropoiesis-stimulating agents and bone-modifying agents require prior authorization; specific J/Q codes are listed in the policy (examples include J1449, J1442, J2820, J0885, J0897).

Examples: J1449, J1442, Q5110, Q5125, J2820 (colony‑stimulating factors)
Erythropoiesis‑stimulating agent example: J0885 (Procrit)
Bone‑modifying agent example: J0897 (Denosumab/Xgeva)

Key Definitions and Notes

Emergency/urgent care — Prior authorization is not required for emergency or urgent care

Emergency/urgent carePrior authorization is not required for emergency or urgent care.

Submission methodsProviders should submit PA requests via the UnitedHealthcare Provider Portal or by phone (855-766-0344).

Out-of-network noteOut-of-network providers must request prior authorization for all procedures and services (separate requirement).

Out-of-network prior authorization — Out-of-network clinicians must request prior authorization for procedures and services

RequirementOut-of-network physicians, facilities and other health care professionals must request prior authorization for all procedures and services.

Context

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior Authorization Requirements for Rhode Island Medicaid

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateFeb. 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization requests via the UnitedHealthcare Provider Portal or call 855-766-0344.

SourceLink

On This Page

Prior Authorization

Cardiology outpatient and office-based diagnostics require prior authorization

Prior authorization is required for outpatient and office-based cardiology diagnostic catheterizations, echocardiograms, electrophysiology implants and stress echoes prior to performance.

Includes lower extremity angiogram and related vascular procedures

Prior Authorization

Prior authorization required for outpatient injectable chemotherapy (J0801)

Prior authorization is required for injectable chemotherapy drugs administered in an outpatient setting; the policy specifically lists J0801.

Applies to outpatient administration of injectable chemotherapy (J0801)

Prior Authorization

Chemotherapy injectable drugs (J9000–J9999 and specified J-codes) require prior authorization

Prior authorization is required for chemotherapy injectable drugs including J9000–J9999 and specified agents (e.g., Leucovorin J0640; Levoleucovorin J0641, J0642; Lupron Depot J1950; Leuprolide J1954; Lanreotide J1932) when used for a cancer diagnosis.

Includes IV, intravesical and intrathecal administration as noted in the Chemotherapy section

Prior Authorization

Prior authorization required for cochlear and auditory implants

Cochlear and other auditory implants require prior authorization; the policy lists multiple CPT/HCPCS procedure and supply codes (examples: 69710, 69714, 69930, L8614, L8619, L8690–L8692).

Procedure examples: 69710, 69714, 69930
Supply/implant HCPCS examples: L8614, L8619, L8690, L8691, L8692

Prior Authorization

CGM prior authorization required with Type 2 Diabetes diagnosis

Continuous glucose monitors require prior authorization when prescribed for a Type 2 Diabetes diagnosis; listed HCPCS codes include A4226, A4239, A9276 and A9277.

CGM HCPCS codes: A4226, A4239, A9276, A9277
Prior authorization condition: Type 2 Diabetes diagnosis

Prior Authorization

CGM prior authorization — Type 2 Diabetes diagnosis required

Continuous glucose monitor prior authorization: prior authorization is required with a Type 2 Diabetes diagnosis for CGM devices (policy reiterates the Type 2 Diabetes diagnosis requirement).

Documentation Required

Selected CPT/HCPCS codes included in prior authorization lists (examples)

The policy lists multiple CPT/HCPCS codes that relate to prior authorization sections (examples shown include CPT 67966 and 67961 and HCPCS Q2026); these codes are included in the policy's PA code listings.

Examples from the list: CPT 67966, CPT 67961, HCPCS Q2026

Documentation Required

ICD‑10 codes tied to reconstructive procedures (restore physiologic function)

The policy associates multiple ICD‑10 codes with reconstructive procedures that 'treat a medical condition or improve or restore physiologic function' (examples include C43.60, C43.61, C43.62, C43.70, C43.71, C43.72).

ICD‑10 examples shown: C43.60, C43.61, C43.62, C43.70, C43.71, C43.72
Context: codes appear under reconstructive/physiologic‑function category

Documentation Required

CPT/HCPCS and ICD‑10 fragments appear in PA tables (incomplete)

The document contains repeated CPT/HCPCS and diagnosis code fragments in PA tables; these fragments (e.g., C44.01, C44.02, C44.09, C44.101) are presented alongside placeholders for CPT/HCPCS and additional information but the table is partially corrupted.

Diagnosis code fragments shown: C44.01, C44.02, C44.09, C44.101
Note: presentation is fragmentary in the source

Documentation Required

CPT/HCPCS code lists reference prior authorization (partial)

Sections of the policy include lists of CPT/HCPCS codes and ICD‑10 codes and mention prior authorization; some fragments list codes without full procedural context in the excerpt.

Prior Authorization

Submit prior authorization for listed C44 cosmetic/reconstructive ICD‑10 codes

Submit prior authorization for the listed C44 series ICD‑10 codes when applicable; the policy provides an extensive C44 code list under Cosmetic and Reconstructive headings for PA reference.

Examples include C44.1021, C44.1022, C44.1091, through many other C44.* codes in the series

Documentation Required

Continued C44 ICD‑10 code list for prior authorization

Additional C44 series ICD‑10 codes are continued in the policy's listing; these codes are presented as part of the Cosmetic and Reconstructive prior authorization code set.

Prior Authorization

Enteral and in‑home nutritional services require prior authorization

Enteral services and in‑home nutritional therapy require prior authorization; the policy lists HCPCS codes such as B4034, B4035, B4036, B4100 and B4102–B4161 for these services.

Enteral HCPCS examples: B4034, B4035, B4036, B4100
In‑home nutrition examples: B4102, B4103, B4104, B4149, B4150, B4152–B4161

Prior Authorization

FAI procedure prior authorization (29914–29916)

Femoroacetabular impingement (FAI) procedures require prior authorization; listed CPT codes include 29914, 29915 and 29916.

FAI CPT examples: 29914, 29915, 29916

Prior Authorization

FESS procedures require prior authorization (listed CPT codes)

Functional endoscopic sinus surgery (FESS) procedures require prior authorization; listed CPT codes include 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287 and 31288.

FESS CPT examples: 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288

Prior Authorization

Gender dysphoria surgical treatment requires prior authorization

Surgical treatment for gender dysphoria requires prior authorization; the policy lists surgical CPT codes (e.g., 55970, 55980) and associated diagnosis codes F64.0, F64.1, F64.2 and F64.8.

Surgical CPT examples: 55970, 55980
Associated diagnoses: F64.0, F64.1, F64.2, F64.8

Prior Authorization

DME, orthotics/prosthetics and assistive device prior authorization and thresholds

Durable medical equipment (DME), orthotics/prosthetics and assistive devices are listed with many HCPCS/K codes; prior authorization is noted for numerous entries and a retail‑price threshold (> $500) applies to some DME codes.

DME examples: A9279, A9280, A9900, E0194, E0265, E0270, E0470, E0471
Note: prior authorization required only for DME with retail purchase or cumulative rental cost over $500 (per policy)

Prior Authorization

Prior authorization/notification required for genetic/molecular testing (e.g., BRCA)

Genetic and molecular testing performed in an outpatient setting (including BRCA testing) requires prior authorization/notification before DNA sequencing; the ordering provider must notify the laboratory and complete the prior authorization/notification process.

BRCA CPT examples: 81162, 81163, 81164, 81228, 81229
Ordering provider responsibility: notify the laboratory and complete PA/notification prior to sequencing

Prior Authorization

Facility notification and prior authorization requirements for post‑acute inpatient facilities

Notification with service detail (e.g., CPT/HCPCS code) is required and prior authorization plus admission‑date notification is required for specified post‑acute inpatient facilities (acute care hospitals, acute inpatient rehabilitation, critical access hospitals, long‑term acute care hospitals, skilled nursing facilities).

Notification must include service detail (CPT/HCPCS)
Applies to listed post‑acute inpatient facility types

Prior Authorization

Injectable drug PA notes and effective dates (Q5133/Q5135 and other drug PA notes)

Certain injectable drug Q‑codes (Q5133 and Q5135) require prior authorization effective Oct. 1, 2024; the policy also notes that prior authorization is not required for an ESRD diagnosis for specified drugs and lists white blood cell colony‑stimulating factor codes requiring PA for oncology and non‑oncology diagnoses.

Effective Oct. 1, 2024: Q5133 and Q5135 require prior authorization
Prior authorization not required for ESRD diagnosis (per policy note)
White blood cell colony‑stimulating factor codes (e.g., J1442, J1447, J1448, J2506, Q5101, Q5108, Q5110, Q5111, Q5120, Q5122) require PA for both oncology and non‑oncology diagnoses

Prior Authorization

Prior authorization for unclassified/temporary HCPCS/J codes (C9399, J3490, J3590)

For unclassified/temporary codes C9399, J3490 and J3590 the policy requires prior authorization for specified high‑cost or gene‑therapy products (examples named in the policy).

Policy names specific products billed under unclassified/temporary codes that require PA (e.g., Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Xenpozyme, Amtagvi, Lenmeldy, Skysona, Tecelra)
Note on Tzield: use of J3490/J3590 only effective April 1, 2023 (per source)

Note

OptumRx prior notification required for certain medications

Some medications require prior notification through OptumRx; the policy gives examples (Cimzia, Synagis) and provides the OptumRx prior notifications phone number.

OptumRx prior notification phone: 800-310-6826
Examples needing OptumRx prior notification: Cimzia, Synagis

Prior Authorization

How to obtain prior authorization — alternate contact

Alternate instructions: Submit prior authorization requests online at UHCprovider.com (sign in and use the Prior Authorization and Notification tool) or call 866-889-8054 for assistance.

Prior Authorization

Prior authorization required — Radiology advanced imaging and select services

Radiology advanced outpatient imaging procedures (certain CT, MRI, MRA, PET scans, and nuclear medicine/cardiology procedures) and select services (e.g., private duty nursing, prostate procedures) require prior authorization.

Care providers ordering advanced outpatient imaging are responsible for notification prior to scheduling
Contact portal or 866-889-8054 to submit PA for radiology as directed

Prior Authorization

Site‑of‑Service PA rule — outpatient hospital vs ASC

Site‑of‑service rule: prior authorization is required only when requesting a listed service in an outpatient hospital setting; prior authorization is not required if the service is performed at a participating Ambulatory Surgery Center (ASC).

Exception: participating ASCs — PA not required

Prior Authorization

Site‑of‑Service (SOS) — outpatient hospital PA requirement reiterated

Prior authorization is only required when requesting the service in an outpatient hospital setting; the policy reiterates that PA is not required if performed at a participating ASC (example context provided with auditory system code 69205).

Example CPT/HCPCS context: auditory system listing includes 69205

Prior Authorization

Cardiovascular procedure codes require PA when performed in outpatient hospital

Cardiovascular system procedure codes listed for PA when performed in an outpatient hospital setting include examples such as 36590 and 36832 (see policy's cardiovascular code list).

Examples: 36590, 36832

Prior Authorization

Carpal tunnel surgery (64721) — prior authorization listed

Carpal tunnel surgery (CPT 64721) is included in the policy's list of procedures that require prior authorization when applicable.

Prior Authorization

Cataract surgery codes included in prior authorization list

Cataract surgery codes are included in the PA listings (examples: 66821, 66982, 66984, 66987, 66988).

Example CPT codes: 66821, 66982, 66984, 66987, 66988

Prior Authorization

Colonoscopy CPT codes included for prior authorization

Colonoscopy procedure codes are listed in the policy's PA code lists (examples include 45378, 45380, 45384, 45385).

Colonoscopy CPT examples: 45378, 45380, 45384, 45385

Prior Authorization

Cosmetic and reconstructive procedures — PA code listings

Cosmetic and reconstructive procedure codes are listed for prior authorization review; the policy provides numerous CPT examples (e.g., 13101, 13132, 14040, 14060, 14301, 21552, 21931).

Examples: 13101, 13132, 14040, 14060, 14301, 21552, 21931
ICD‑10 C44 series codes are provided in the cosmetic/reconstructive code set

Prior Authorization

Digestive system procedures listed for prior authorization

Digestive system procedure codes are listed in the policy's PA section; multiple CPT examples are provided (e.g., 42415, 43200, 44360, 45334).

Examples: 42415, 43200, 44360, 45334, among others

Prior Authorization

ENT procedures require prior authorization (listed CPT codes)

ENT procedure codes requiring prior authorization are listed (examples include 21320, 30140, 30520, 69436, 69631).

ENT CPT examples: 21320, 30140, 30520, 69436, 69631

Prior Authorization

Eye and ocular adnexa procedures included in prior authorization list

Eye and ocular adnexa procedure codes are included in the PA listings (examples: 65710, 65820, 66250, 66710, 66986, 67010).

Examples: 65710, 65820, 66250, 66710, 66986, 67010

Documentation Required

CPT/HCPCS reference and PA submission instructions

The policy references CPT/HCPCS codes and how to obtain prior authorization in multiple sections; providers should consult the listed codes and the portal or phone contacts for PA submission.

Prior Authorization

Gynecologic procedures included in PA listings

Gynecologic procedure codes are listed in the prior authorization sections (examples include 57240, 57250, 57522, 58562).

Gynecologic CPT examples: 57240, 57250, 57522, 58562

Prior Authorization

Hemic and lymphatic system procedures require prior authorization

Hemic and lymphatic system procedure codes are listed for prior authorization (examples: 38500, 38510).

Examples: 38500, 38510

Prior Authorization

Hernia repair CPT codes included in PA list

Hernia repair procedure codes are listed for prior authorization review (examples: 49505, 49650).

Examples: 49505, 49650

Prior Authorization

Integumentary system procedures included in prior authorization lists

Integumentary system procedure codes are listed in the policy's PA tables (examples include 10121, 11440, 11770, 13121, 15240, 19020).

Examples: 10121, 11440, 11770, 13121, 15240, 19020

Prior Authorization

Liver biopsy (47000) listed for prior authorization

Liver biopsy (CPT 47000) is included in the prior authorization code listings.

Prior Authorization

Male genital system procedure (54840) listed for PA

Male genital system procedure code (CPT 54840) is listed in the policy's PA code sections.

Prior Authorization

Miscellaneous procedure (20680) included in PA list

Miscellaneous procedure CPT 20680 is listed in the prior authorization sections.

Prior Authorization

Musculoskeletal procedure codes and mappings for prior authorization

Musculoskeletal system procedure codes and mappings are listed for prior authorization when performed in the outpatient hospital setting; the policy provides many CPT examples and mapping notes.

Examples include 20552, 21336, 21930 and multiple associated mapping entries

Prior Authorization

Nervous system procedures included in PA listings

Nervous system procedure codes requiring prior authorization are listed (examples include 64561 and 64640).

Examples: 64561, 64640

Prior Authorization

Sleep studies require prior authorization (95805–95811)

Sleep studies require prior authorization; listed CPT codes include 95805, 95807, 95808, 95810 and 95811.

Sleep study CPT examples: 95805, 95807, 95808, 95810, 95811

Prior Authorization

Spinal surgery prior authorization for listed CPT codes

Spinal surgery procedures require prior authorization for the listed CPT codes (examples beginning with 221xx and related spinal CPT ranges are provided in the policy).

Examples include codes in the 22100–222xx series as shown in the spinal surgery entries

Prior Authorization

Sleep apnea procedures and surgeries require prior authorization

Sleep apnea procedures and surgeries are indicated as requiring prior authorization in the policy (the excerpt states PA required though not all specific codes are present in the fragment).

Maxillomandibular advancement and other sleep apnea surgeries are noted as requiring PA

Prior Authorization

Transplant and CAR T‑Cell therapies require prior authorization — contact transplant case management

Prior authorization is required for transplant and CAR T‑Cell therapy services; providers are instructed to contact the UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246 (or the notification number) for these services.

Contact for transplant/CAR T‑Cell PA: UnitedHealthcare Community and State Transplant Case Management Team at 888-936-7246

Prior Authorization

Vein procedures require prior authorization

Vein procedures require prior authorization; the policy lists vein procedure CPT examples (e.g., 36473, 36475) and states PA is required.

Vein procedure CPT examples: 36473, 36475

This is stated alongside provider submission instructions in the General Information section.

Submission optionsOnline via Provider Portal or by phone (855-766-0344).

Cochlear and other auditory implants — definition/term present in document

TermCochlear and other auditory implants (inner-ear medical device with external portion to help persons with profound sensorineural deafness achieve conversational function).

HCPCS examplesL8619, L8690, L8691, L8692 listed in implant entries.

PA requirementPrior authorization required for cochlear and other auditory implants (multiple procedural and supply codes listed).

Continuous glucose monitor (CGM) — term present in document

TermContinuous glucose monitor (CGM).

HCPCS codesA4226, A4239, A9276, A9277 are listed for CGM in the document.

PA note referenceCGM entries include 'Additional Information = Prior authorization required with Type 2 Diabetes Diagnosis.'

Continuous glucose monitor prior auth note — Prior authorization required with Type 2 Diabetes Diagnosis

RequirementPrior authorization required for continuous glucose monitors when the member has a Type 2 Diabetes diagnosis.

CodesA4226, A4239, A9276, A9277

Document citationExplicit PA note: 'Prior authorization required with Type 2 Diabetes Diagnosis.'

Reconstructive procedures — definition: treat a medical condition or improve/restore physiologic function

DefinitionReconstructive procedures: procedures that treat a medical condition or improve or restore physiologic function.

ExamplesReconstructive CPT codes listed (e.g., 21280, 21282, 21295, 21740 and eyelid/ocular series 67902–67966 series).

Coverage contextThese procedures are listed under reconstructive classification for prior authorization reference.

Cosmetic procedures — definition: change or improve physical appearance

DefinitionCosmetic procedures: procedures that change or improve physical appearance.

ExamplesCosmetic CPT codes shown include 15821–15830 series and 15879, 17106–17108 among others.

DistinctionDocument contrasts cosmetic procedures with reconstructive procedures where physiologic function is restored/improved.

Reconstructive procedures (duplicate definition)

Definition (duplicate)Reconstructive procedures: 'procedures that treat a medical condition or improve or restore physiologic function.'

Associated codesReconstructive-related codes repeatedly appear (e.g., 67904–67966 series, Q2026 references).

UsageUsed to classify procedures for prior authorization determinations in the document.

Cosmetic procedures (duplicate definition)

Definition (duplicate)Cosmetic procedures: 'procedures that change or improve physical appearance without significantly improving or restoring physiological function.'

Associated codesCosmetic codes and C43/C44 diagnosis groupings are used to label cosmetic vs reconstructive intent.

ContextDocument repeatedly distinguishes cosmetic vs reconstructive for PA handling.

ICD-10 diagnosis code group appearing in the fragment (skin neoplasm codes — C44.xx)

ICD-10 groupSkin neoplasm / non-melanoma skin cancer diagnosis codes referenced: C44.xx (multiple specific C44 codes listed).

ExamplesFragmentary entries include C44.01, C44.02, C44.09, C44.101 and longer C44 series listings in cosmetic/reconstructive sections.

UseThese ICD-10 codes are used in the cosmetic/reconstructive code lists for PA reference.

cosmetic/reconstructive label (as labeled in code list)

Labelcosmetic/reconstructive (as labeled in code list)

UsageDocument groups many ICD-10 codes under 'Cosmetic and reconstructive' headings for PA processing.

ExamplesMultiple C44 series codes shown under this label (see chunk 124).

Durable medical equipment (DME) — term present in document

TermDurable medical equipment (DME).

PA thresholdDME requires prior authorization when listed DME items meet the retail threshold (> $500) or as otherwise noted in DME entries.

ExamplesDME HCPCS listed in document include A9279, A9280, A9900, E0194, E0265, E0266, E0270, E0277, etc.

Enteral services / In-home nutritional — term present in document

TermEnteral services / In-home nutritional therapy.

PA requirementEnteral services and in-home nutritional services require prior authorization (specific B4xxx HCPCS codes listed).

Example HCPCSB4034, B4035, B4036, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4155, etc.

Notification/prior authorization required for certain genetic and molecular tests — ordering provider responsibilities noted

RequirementNotification/prior authorization required for certain genetic and molecular tests (e.g., BRCA) performed in outpatient settings; ordering provider must notify the laboratory and complete the PA/notification process.

BRCA specificsNotification/prior authorization required before DNA sequencing is performed for BRCA codes (e.g., 81162–81164, 81228–81229, and related sequencing codes).

Provider actionOrdering provider must notify the laboratory conducting the test and indicate test details as part of the PA process.

Post-acute inpatient facilities — list of facility types requiring notification/PA

Facility typesPost-acute inpatient facilities requiring notification/PA: acute care hospitals; acute inpatient rehabilitation; critical access hospitals; long-term acute care hospitals; skilled nursing facilities.

RequirementNotification with service detail (e.g., CPT/HCPCS code) and admission date is required for these facilities providing post-acute inpatient services.

ReferenceSee 'Additional Information' post-acute facility list for PA/notification instructions.

Unclassified/temporary codes (C9399, J3490, J3590) — used for new/unclassified medications

Unclassified/temporary codes useC9399, J3490, J3590 are used for new or unclassified medications; prior authorization is required for listed high-cost medications referenced under these codes.

ExamplesDocument lists products such as Casgevy, Lantidra, Nulibry, Revcovi, Rivfloza, Xenpozyme and others that require PA when billed to J3490/J3590/C9399.

Effective notesTzield use of J3490/J3590 only effective April 1, 2023 (document notes date-specific handling).

Proton Beam — definition present in document

TermProton Beam: focused radiation therapy that uses beams of protons.

Codes referencedRelevant CPT entries and mappings (e.g., 77520 series) are included under Radiation/Proton Beam sections.

PA contextRadiation therapy services are listed under Radiology prior authorization requirements for advanced outpatient imaging and therapy procedures.

Radiology prior authorization — definition/term present (advanced outpatient imaging requires PA)

TermRadiology prior authorization: prior authorization required for advanced outpatient imaging including certain CT, MRI, MRA, PET and nuclear medicine/nuclear cardiology procedures.

Provider responsibilityCare providers ordering advanced outpatient imaging are responsible for providing notification prior to scheduling.

Submission optionsSubmit PAs via UnitedHealthcare Provider Portal or by phone per general instructions in document.

Site of Service (SOS) — definition and note that PA only required in outpatient hospital setting

DefinitionSite of Service (SOS): Prior authorization only required when requesting service in an outpatient hospital setting; not required if performed at a participating Ambulatory Surgery Center (ASC).

ExampleDocument explicitly states SOS rule and lists example CPTs where SOS applies.

Practical noteWhen scheduling, verify whether the service is to be performed in outpatient hospital SOS to determine PA requirement.

Site of service (SOS) - outpatient hospital duplicate definition

Definition (duplicate)Site of service (SOS) - outpatient hospital: prior authorization required when requesting service in an outpatient hospital setting; not required if performed at a participating ASC.

Code example69205 shown under Auditory System with SOS note as an example of SOS application.

Operational impactProviders should confirm participating ASC status to avoid unnecessary PA submissions.

Prior authorization required — generic definition note (e.g., sleep studies require PA)

DefinitionPrior authorization required — generic note indicating listed procedure categories (e.g., sleep studies) require prior authorization before being performed or billed.

Example codesSleep study codes listed: 95805, 95807, 95808, 95810, 95811.

ActionSubmit PA prior to scheduling these services per provider instructions.

Unclassified J/C codes — PA note for gene therapy and specific high-cost products

RuleUnclassified J/C codes (J3490, J3590, C9399) require prior authorization for specified gene therapy and other high-cost products identified in the document.

ExamplesProducts called out include Amtagvi, Lenmeldy, Skysona, Tecelra, and others listed under unclassified code entries.

Provider instructionProviders should follow PA/notification instructions and check product-specific notes and effective dates included in the document.

38232 PA exception — Code 38232 requires PA only for oncology diagnosis

ExceptionCode 38232 will only require prior authorization for an oncology diagnosis.

Source linesExplicitly stated in Bone growth stimulator / related sections and repeated in fragmentary notes.

ImplicationFor non-oncology diagnoses, 38232 does not require PA per this document excerpt.